Provider Demographics
NPI:1023642774
Name:YOUNG, SOPHIA PASQUALINA
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:PASQUALINA
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SOPHIA
Other - Middle Name:PASQUALINA
Other - Last Name:BLACKDEER-YOUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1880 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-5629
Mailing Address - Country:US
Mailing Address - Phone:916-729-3098
Mailing Address - Fax:
Practice Address - Street 1:1880 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-5629
Practice Address - Country:US
Practice Address - Phone:916-729-3098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician